Fracture of the neck of the humerus (Fracture of the neck of the humerus). Shoulder joint: structure, functions, photo Anatomical neck of the humerus

According to statistics, 7% of fractures occur in the humerus. Such damage occurs mainly due to falls and impacts. Fractures of the humerus are possible in different parts of it, which is accompanied by different symptoms and sometimes requires separate approaches to treatment.

Anatomical structure

The humerus is divided into three parts: the body or diaphysis is the middle part, and the ends are called epiphyses. Depending on the location of the damage, they speak of fractures of the upper, middle or lower part of the shoulder. The upper section is also called proximal, and the lower is called distal. The diaphysis is divided into thirds: upper, middle and lower.

In turn, the epiphyses have a complex structure, since they are the ones that enter the joints and hold the muscles. At the top of the humerus there is a semicircular head and an anatomical neck - the area immediately below the head. They and the articular surface of the scapula enter the shoulder joint. Under the anatomical neck there are two tubercles, which serve as attachment points for muscles. They are called the greater and lesser tubercle. The bone tapers even further, forming the so-called surgical neck of the shoulder. The lower part of the humerus is represented by two articular surfaces at once: the head of the condyle, which has a rounded shape, articulates with the radius of the forearm, and the block of the humerus leads to the ulna.

Main types of fractures

Fractures are classified according to several parameters. On the one hand, fractures of the humerus are grouped by location, i.e., by department. So, a fracture is distinguished:

- in the proximal (upper) section;

- diaphysis (middle section);

- in the distal (lower) section.

In turn, these classes are further divided into varieties. In addition, a fracture may occur in several places at once within one department or in neighboring ones.

On the other hand, injuries can be divided into fractures with and without displacement, as well as comminuted (comminuted) fractures. There are also open injuries (with damage to soft tissues and skin) and closed ones. At the same time, the latter predominate in everyday life.

Specification of the type of fracture by department

A proximal fracture can be classified as intra-articular or extra-articular. With intra-articular (supratubercular) the head itself or the anatomical neck of the bone may be damaged. Extra-articular is divided into a fracture of the tubercle of the humerus and a fracture of the underlying surgical neck.

When the diaphysis is damaged, several subtypes are also distinguished: fracture of the upper, middle or lower third. The nature of the bone fracture is also important: oblique, transverse, helical, comminuted.

The distal portion may also be affected in various ways. It is possible to distinguish a supracondylar extra-articular fracture, as well as fractures of the condyles and trochlea, which are classified as intra-articular. A deeper classification distinguishes flexion and extension supracondylar, as well as transcondylar, intercondylar U- or T-shaped and isolated fracture of the condyles.

Prevalence

In everyday life, due to falls and blows, the surgical neck of the upper part, the middle third of the diaphysis, or the epicondyles of the lower part of the humerus mainly suffer. Closed fractures predominate, but very often they can be displaced. It should also be noted that several types of fractures can be combined simultaneously (usually within one department).

Fractures of the humeral head, anatomical and surgical neck most often occur in older people. The lower section often suffers in children after an unsuccessful fall: intercondylar and transcondylar fractures are not uncommon in them. The body of the bone (diaphysis) is susceptible to fractures quite often. They occur when struck on the shoulder, as well as when falling on the elbow or straightened arm.

Proximal fractures

Intra-articular fractures include a fracture of the head of the humerus and the anatomical neck located immediately behind it. In the first case, a comminuted fracture may occur or a dislocation may additionally occur. In the second case, an impacted fracture may occur, when a fragment of the anatomical neck is embedded in the head and can even destroy it. With direct trauma without avulsion, the fragment can also be crushed, but without significant displacement.

Also, injuries to the proximal part include fractures of the greater tubercle of the humerus and the lesser: transtubercular and avulsions of the tubercles. They can occur not only when falling on the shoulder, but also when the muscles contract too strongly. A fracture of the tubercle of the humerus can be accompanied by fragmentation without significant displacement of the fragment or by its movement under the acromedial process or down and outward. This injury can occur from direct trauma or dislocation of the shoulder.

The most common fracture is the surgical neck of the humerus. The cause most often is a fall. If the arm was abducted or adducted at the time of the injury, an abduction or adduction fracture of the bone is noted; if the limb is in the middle position, an impacted fracture may result when the distal fragment is embedded in the overlying section.

A fracture can occur in several places at the same time. The bone is then divided into two to four fragments. For example, a fracture of the anatomical neck may be accompanied by a separation of one or both tubercles, a fracture of the surgical neck may be accompanied by a fracture of the head, etc.

Symptoms of a fracture in the upper part of the shoulder

An intra-articular fracture is accompanied by swelling of the area or even hemorrhage into the joint. Visually, the shoulder increases in volume. Pressing on the head is painful. A fracture of the neck of the humerus gives pain during circular movements and palpation. With an impacted fracture of the surgical neck, movement in the shoulder joint may not be impaired. If there is a displacement, the axis of the limb may change. There may be hemorrhage, swelling, or simply swelling in the joint area. When a characteristic bony protrusion appears on the anterior outer surface of the shoulder, we can speak of an adduction fracture, and if a retraction appears there, then this indicates an abduction fracture.

Also, a surgical fracture of the humerus can cause abnormal mobility. Fractures with large displacement or comminution can block active movements, and even minor axial loads and passive movements cause sharp pain. The most dangerous option is in which a fracture of the neck of the humerus occurs with additional damage, pinching, and compression of the neurovascular bundle. Compression of this bundle causes swelling, decreased sensitivity, venous congestion and even paralysis and paresis of the arm.

A fracture of the greater tubercle of the humerus gives pain in the shoulder, especially when turning the arm inward. Movements in the shoulder joint are impaired and become painful.

Symptoms of a diaphysis fracture

Fractures of the humerus in the diaphysis area are quite common. There is swelling, pain and uncharacteristic mobility at the site of injury. The fragments can move in different directions. Hand movements are impaired. Hemorrhages are possible. Severely displaced fractures are visible even to the naked eye by the deformation of the shoulder. If the radial nerve is damaged, it is impossible to straighten the hand and fingers. However, to study the nature of the damage, an x-ray is needed.

Distal fractures and their symptoms

Distal fractures are divided into extra-articular (supracondylar extension or flexion) and intra-articular (condylar, transcondylar, fractures of the capitate eminence or trochlea of the humerus). Disturbances in this department lead to deformation of the elbow joint itself. There is also pain and swelling, and movement becomes limited and painful.

Supracondylar flexion injuries occur after a fall on a bent arm, leading to edema, swelling over the site of injury, pain and elongation of the forearm noticeable to the naked eye. Extensor pain occurs when the arm is hyperextended during a fall; they visually shorten the forearm and are also accompanied by pain and swelling. Such fractures can also be combined with simultaneous dislocation in the joint.

Fractures of the external condyle most often accompany a fall on an outstretched arm or direct injuries, while the internal one breaks when falling on the elbow. There is swelling in the elbow area, pain, and sometimes bruising or bleeding into the joint itself. Movement in the elbow joint is limited, especially with hemorrhage.

A fracture of the capitate eminence can occur when falling on a straight arm. Movement in the joint is also limited and pain occurs. Typically, this is a closed fracture of the humerus.

First aid and diagnostics

If a fracture is suspected, the limb must be properly fixed to prevent the situation from worsening. You can also use analgesics for pain relief. After this, the victim should be taken to the hospital as soon as possible for accurate diagnosis and professional assistance.

A fracture can be diagnosed based on the above symptoms, but definitive results can only be obtained after radiography. Usually pictures are taken in different projections to clarify the full picture. Fractures of the humerus are sometimes not clearly expressed; they are then difficult to distinguish from dislocations, sprains and bruises, which require different treatment.

Treatment of minor fractures

A non-displaced humerus fracture requires immobilization of the limb with a cast or abduction splint. Complications here are extremely rare. If a slight displacement is observed, then reposition is performed followed by immobilization. In some cases, it is enough to install a removable splint, in others, complete fixation is required.

Minor fractures of the proximal part make it possible to perform UHF and magnetic therapy within three days, and after 7-10 days to begin developing the elbow and wrist joints, conduct electrophoresis, ultraviolet radiation, massage and ultrasound. After 3-4 weeks, the plaster cast, splint or special fixatives are replaced with a bandage, continuing exercise therapy and procedures.

Restoring displaced fragments without surgery

More serious injuries, such as a surgical neck fracture or a displaced humerus fracture, require reduction, a cast, and regular x-ray monitoring in a hospital setting. The cast can be applied for 6-8 weeks. In this case, it is necessary to move the hand and fingers from the next day; after 4 weeks, you can perform passive movements of the shoulder joint, helping with your healthy arm, then move on to active movements. Further rehabilitation includes exercise therapy, massage and mechanotherapy.

The need for surgical interventions

In some cases, reposition is not possible due to severe fragmentation or simply does not give the desired results. If such a fracture of the humerus is present, treatment is required with surgery to achieve alignment of the fragments. Strong displacements, fragmentation or fragmentation, instability of the fracture site may require not just reduction, but also osteosynthesis - fixation of the fragments with knitting needles, screws, plates. For example, a fracture of the neck of the humerus with complete divergence of the fragments requires fixation with a Kaplan-Antonov plate, wires, a Vorontsov or Klimov beam, a pin or a rod, which avoids the occurrence of angular displacement during fusion. The fragments are held until fusion with screws or an Ilizarov apparatus. Skeletal and adhesive traction are additionally used for comminuted fractures of the lower part, after which a splint is applied and therapeutic exercises are performed.

Non-displaced epicondyle fractures require wearing a plaster cast for 3 weeks. Displacement may require surgical intervention. Condylar (intercondylar and transcondylar) fractures are often accompanied by displacement of fragments and are operated on. In this case, reposition is performed open to ensure that the correct position of the articular surfaces is restored and to perform osteosynthesis. Next, restorative treatment is used in a complex.

Treatment of complicated fractures

A displaced fracture of the humerus, accompanied by damage to the radial nerve, requires comparison of bone fragments and conservative treatment of the nerve itself. The fracture is immobilized and supplemented with drug therapy so that the nerve can regenerate itself. Later, exercise therapy and physiotherapy are added. But if the functionality of the nerve is not restored after several months, then surgery is performed.

In the most difficult cases, when the bones are too fragmented, the fragments can be removed, after which prosthetics are required. An endoprosthesis is used in the shoulder joint instead of the head. If there is excessive damage to the tubercle, the muscles can be sutured directly to the humerus.

Treatment of any fracture requires compliance with all recommendations of specialists, as well as a serious approach to rehabilitation. Immobilization and complete rest of the damaged surface are replaced over time by certain loads. Courses of physiotherapy, physical therapy, massage and similar procedures can be prescribed repeatedly with some breaks until complete recovery. It is also important to conscientiously follow all instructions for rehabilitation at home and protect yourself from re-injury.

Fracture of the shoulder and humerus and its treatment

Good day to all. Today we have another article on the topic of injuries and fractures. Today we will look at all types of fractures of the shoulder and humerus, and also talk about rehabilitation procedures for such injuries.

Humerus fracture

The humerus is a long bone of the upper limb, which is anatomically divided into a body (diaphysis) and two ends (epiphyses). About 7% of all fractures in traumatology are fractures of the humerus and the main cause is impacts and falls. All of these injuries are types of arm fracture.

A shoulder fracture is accompanied by deformation of the shoulder, abnormal mobility in one area or another, pain and severe swelling.

When providing first aid, correct fixation of the hand is necessary, the use of analgesics is indicated, and timely hospitalization of the victim is necessary.

Anatomical features of the humerus

At the top, the humerus forms a semicircular head, which, together with the articular surface of the scapula, forms the shoulder joint. The area located just below the head is called the anatomical neck of the humerus. Just below the anatomical neck are the lesser and greater tubercles, to which the muscles are attached. The slight narrowing of the bone inferior to the tuberosities is called the surgical neck of the shoulder.

The lower part of the humerus contains two articular surfaces: the rounded head of the condyle, which articulates with the radius, and the trochlea of the humerus, which faces the ulna.

What are the types of fractures of the shoulder and humerus?

Depending on the damage to one or another part of the humerus, the following types of fractures are distinguished:

A fracture in the proximal part, which, in turn, is divided into intra-articular (fracture of the head and anatomical neck of the shoulder joint) and extra-articular (fracture of the tubercle of the humerus and fracture of the surgical neck).

Fracture of the diaphysis of the shoulder (fracture of the upper, middle or lower third is distinguished).
Distal fracture.

There are supracondylar and condylar fractures (transcondylar, T- and U-shaped intercondylar and isolated condylar fractures)

In most cases, there is a fracture of the upper end of the shoulder in the area of the surgical neck, as well as a fracture in the middle third of the shoulder and at the location of the epicondyles in the lower third. As a result of domestic trauma, a closed fracture of the humerus most often occurs, which is not accompanied by damage to the skin. Such fractures are the easiest to treat and often do not cause complications.

Proximal humerus fracture

Intra-articular fracture (fracture of the head of the humerus or anatomical neck of the shoulder) occurs mainly in older people. A fracture of the anatomical neck is characterized by penetration of the fragment into the head with the formation of a so-called impacted fracture. In case of a strong blow, the head between the articular surface of the scapula and the distal fragment may be destroyed.

Symptoms of a proximal humerus fracture:

An increase in the volume of the shoulder due to swelling and hemorrhage into the joint cavity (hemarthrosis).
Comminuted head fractures and neck fractures with significant displacement of fragments are characterized by a complete absence of active movements. With passive movements and axial load, sharp pain occurs. Pressure on the head is accompanied by severe pain.

Taking into account the mechanism of injury, the following are distinguished:

Fracture due to direct trauma.

Accompanied by fragmentation of the fragment without significant displacement.

Avulsion fracture.

It is accompanied by the separation of a small fragment of the greater tubercle, which, under the action of muscles, is displaced either outward and downward, or under the acromedial process. Typically, a greater tuberosity fracture occurs when the shoulder is dislocated.

Surgical humeral neck fracture

With an indirect mechanism of injury, a fracture of the surgical neck of the humerus usually occurs. If at the time of the fall the arm is abducted, an abduction fracture of the shoulder occurs; if the arm is adducted, an adduction fracture of the humerus occurs. When the arm is in the middle position, a fracture more often occurs with the insertion of a distal fragment into the proximal one (impacted fracture of the surgical neck).

The following symptoms are typical for a surgical neck fracture:

Pain when feeling the fracture site, as well as when moving in a circular motion.
During movements, a joint displacement of the greater tubercle and the head occurs (typical of an impacted fracture).
A displaced fracture of the humerus is accompanied by a change in the axis of the limb, swelling and hemorrhage in the joint area. In this case, active movements are impossible, and passive movements are accompanied by severe pain.
Pathological mobility and crepitation of bone fragments may occur.
Adduction fractures are characterized by the appearance of a bony protrusion on the anterior outer surface of the shoulder, while abduction fractures are characterized by retraction.
Shoulder shortening.

A fracture of the humeral neck can be complicated by injury to the neurovascular bundle at the time of trauma or due to improper reposition.

Features of an open fracture of the shoulder

An open fracture of the humerus is accompanied by a wound on the surface of the shoulder and bleeding, to stop which it is necessary to apply a tourniquet in the upper third of the shoulder. Afterwards, a sterile bandage is applied and the arm is immobilized with a splint in the middle position.

Features of diagnosis and treatment

To diagnose a fracture, radiography of the joint in different projections is used.

Treatment of a humerus fracture is carried out by reduction and plaster immobilization. A removable splint is used, which allows the administration of magnetic therapy and UHF from the 3rd day. After a week or 10 days, active movements in the wrist and elbow joints, passive movements in the shoulder joint are indicated, electrophoresis with novocaine, calcium chloride, ultrasound, ultraviolet radiation, and massage are prescribed. After 4 weeks, the plaster is replaced with a scarf and rehabilitation treatment continues.

Treatment of a surgical neck fracture is usually inpatient, using reduction and x-ray control after the cast has dried, which is repeated after a week or 10 days. The cast is applied for up to 8 weeks, from the 5th week - a diverting splint. Active movements of the fingers and hand are shown from the 1st day; after a month it is possible to include passive movements in the shoulder joint using a healthy arm, and then active movements in the shoulder joint.

If necessary, resort to a combined treatment method using skeletal traction for the elbow fragment and a circular plaster cast on the forearm.

Rehabilitation after a fracture of the humerus includes massage, exercise therapy and mechanotherapy.

Restoration of work capacity for a non-displaced fracture occurs after approximately 2 months, and for a displaced fracture – after 2.5 months.

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perelom-kosti.ru Types of humerus fractures and principles of treatment The humerus is quite long, and a fracture can occur in any part of it: anatomical neck of the shoulder (intra-articular fracture); surgical neck of the shoulder (extra-articular fracture); humeral diaphysis (main part of the bone); distal section (closer to the elbow). Fractures of the surgical neck of the humerus are especially dangerous, as they can lead to damage to the neurovascular bundle, which means hemorrhage and possible paresis in the future. Treatment of a humerus fracture is usually conservative (reposition of the fragments, casting and observation), but in some cases surgery may be required. The start of treatment usually coincides with the rehabilitation period. The main goal of rehabilitation is to restore full range of motion. The set of exercises is adjusted by the attending physician and physical therapy doctor individually for each patient. Exercise therapy promotes muscle relaxation, correct alignment of bone fragments, reduces pain, and activates the processes of regeneration and adaptation. Immobilization stage (first 3 weeks after fracture) The entire complex should be performed 6-8 times a day for 30 minutes (6-10 repetitions for each exercise). Starting position – standing with a forward bend. Breathing exercises. The hand must be in a bandage at all times (except for activities). Active movements (rotation, flexion/extension, pronation/supination) in the elbow, wrist joints, and hands stimulate blood circulation in the arm, reducing swelling and reducing the risk of blood clots. Rotate your arms clockwise and counterclockwise. Pendulum-like movements of the hands. This exercise is great for relieving pain at any time. It is enough to remove the sore arm from the bandage and, in a standing position, bending forward, make several pendulum-like swings with the relaxed limb. Abduction and adduction of the arm or just the elbow to the body. Clap in front of the chest and then behind the back. Crossing your arms in front of your chest. Torso twists with hands clasped in front of the chest. Physical treatments include cryotherapy to reduce pain, swelling and inflammation. The patient receives a list of exercises upon discharge home. It is necessary to continue practicing, otherwise it will be impossible to restore the mobility of your hand. Functional stage (3-6 weeks) During this period, the fracture is already considered healed, which is confirmed by x-rays. The goal of rehabilitation at this stage is to restore the previous range of passive and active movements. The set of exercises expands, but the starting position remains the same. The patient should strive for gradual extension and perform exercises while standing without bending forward. Frequency of exercises – 4-6 times a day, up to 6-10 repetitions. Raise your arm straight in front of you. Active use of block exercise machines: raising and lowering the sore limb, raising the arms to the sides. Swing your arms forward, backward, to the sides. Starting position - standing with a slight bend forward. Retraction of the arms behind the back with squeezing of the shoulder blades. Starting position – arms in front of the chest, elbows bent. Water procedures. While visiting the pool, you should perform exercises that imitate breaststroke and freestyle swimming, crossing your arms in front of your chest, and various movements of your limbs. Staying in water puts additional stress on the muscles, which improves blood circulation in them and increases the effectiveness of training. Physiotherapy includes magnet, massage, balneotherapy. Courses of 10-12 procedures. Training stage (7-8 weeks) It is believed that by this time the patient had almost completely restored the functionality of the injured arm and shoulder. Exercises are performed to strengthen muscles and fully restore range of motion. Training should take place 3-4 times a day for 10-12 repetitions. Raise your arm straight in front of you. Starting position: standing straight. Exercises for abduction, adduction, pronation, supination, arm rotation. Hanging on a bar or wall bars, hand rests and push-ups, manipulations with medicine balls and dumbbells weighing no more than 5 kg. It is necessary to continue physical therapy to strengthen the deltoid muscle and rotator cuff, which are the muscular framework for the shoulder joint. It should be borne in mind that exercises that require a large load should not be prescribed to elderly patients. Stretching exercises. “Walking” with your fingers up and to the sides along the wall, placing a towel or gymnastic stick behind your back. The listed manipulations make it possible to achieve complete restoration of mobility in all directions. Swimming pool – swimming in a comfortable style. Physiotherapy still includes magnet, massage, balneotherapy. With a rationally selected rehabilitation scheme, the patient’s full recovery occurs within 2-3 months. Only after this it is necessary to perform exercises designed to develop physical strength, stretching, and endurance. You need to take vitamin complexes and special supplements, and also make sure that there is enough calcium in your food (dairy products). Video “Rehabilitation after a humerus fracture” Fractures of the humerus in the proximal part There are fractures of the head, anatomical neck (intra-articular); transtubercular fractures and surgical neck fractures (extra-articular); avulsions of the greater tubercle of the humerus (Fig. 1). The main types of fractures are given in the AO/ASIF UKP. Rice. 1. Fractures in the proximal part of the humerus: 1 - fractures of the anatomical neck; 2 - transtubercular fractures; 3 - surgical neck fractures Fractures of the head and anatomical neck of the humerus Causes: a fall on the elbow or a direct blow to the outer surface of the shoulder joint. When the anatomical neck is fractured, the distal fragment of the humerus usually becomes wedged into the head. Sometimes the humeral head becomes crushed and deformed. The head can be torn off, with its cartilaginous surface turning toward the distal fragment. Signs. The shoulder joint is increased in volume due to swelling and hemorrhage. Active movements in the joint are limited or impossible due to pain. Palpation of the shoulder joint area and tapping the elbow are painful. During passive rotation movements, the greater tuberosity moves with the shoulder. With concomitant dislocation of the head, the latter cannot be felt in its place. Clinical signs are less pronounced with an impacted fracture: active movements are possible; with passive movements, the head follows the diaphysis. The diagnosis is confirmed by x-ray; an axial projection is required. Mandatory monitoring of vascular and neurological disorders is necessary. Treatment. Victims with impacted fractures of the head and anatomical neck of the humerus are treated on an outpatient basis. 20-30 ml of a 1% solution of novocaine is injected into the joint cavity, the arm is immobilized with a plaster splint according to G.I. Turner in the position of abduction (using a roller, pillow) by 45-50°, flexion in the shoulder joint up to 30°, in the elbow - up to 80-90°. Analgesics, sedatives are prescribed, from the 3rd day they begin magnetic therapy, UHF on the shoulder area, from the 7-10th day - active movements in the wrist and elbow and passive movements in the shoulder joint (removable splint!), electrophoresis of novocaine, calcium chloride , UV irradiation, ultrasound, massage. After 4 weeks the plaster splint is replaced with a scarf bandage, and rehabilitation treatment is intensified. Rehabilitation - up to 5 weeks. Working capacity is restored after 2-21/2 months. Indications for surgery: impossibility of reduction in unstable fractures with significant displacement of fragments, interposition of soft tissues and fragments between articular surfaces (type A3 and more severe). Fractures of the surgical neck of the humerus Causes. Fractures without displacement of fragments are usually impacted or pinched. Fractures with displacement of fragments, depending on their position, are divided into adduction (adduction) and abduction (abduction). Adduction fractures occur when falling with emphasis on the outstretched adducted arm. In this case, the proximal fragment is retracted and rotated outward, and the peripheral fragment is displaced outward, forward and rotated inward. Abduction fractures occur when falling with emphasis on the outstretched abducted arm. In these cases, the central fragment is adducted and rotated inward, and the peripheral fragment is inward and anteriorly displaced forward and upward. An angle is formed between the fragments, open outward and posteriorly. Signs. With impacted fractures and non-displaced fractures, local pain is determined, which increases with load along the axis of the limb and rotation of the shoulder; the function of the shoulder joint is possible, but limited. During passive abduction and rotation of the shoulder, the head follows the diaphysis. The x-ray determines the angular displacement of the fragments. In fractures with displaced fragments, the main symptoms are severe pain, dysfunction of the shoulder joint, pathological mobility at the level of the fracture, shortening and disruption of the axis of the shoulder. The nature of the fracture and the degree of displacement of the fragments are clarified radiographically. Treatment. First aid includes the administration of analgesics (Promedol), immobilization with a transport splint or Deso bandage (Fig. 2), hospitalization in a trauma hospital, where a full examination is carried out, anesthesia of the fracture site, reposition and immobilization of the limb with a splint (for impacted fractures) or a thoracobrachial bandage with mandatory radiographic control after the plaster has dried and after 7-10 days. Rice. 2. Transport immobilization for fractures of the humerus: a, b - Deso bandage (1-5 - bandage stroke); c - ladder bus Features of reposition (Fig. 3): for adduction fractures, the assistant lifts the patient’s arm forward by 30-45° and abducts it by 90°, bends the elbow joint to 90°, rotates the shoulder outward by 90° and gradually smoothly extends it along the axis of the shoulder. The traumatologist controls the reposition and performs corrective manipulations in the area of the fracture. The traction along the axis of the shoulder should be strong; sometimes for this, an assistant applies counter support with the foot in the area of the armpit. After this, the arm is fixed with a thoracobrachial bandage in the position of shoulder abduction to 90-100°, flexion at the elbow joint to 80-90°, extension at the wrist joint to 160°. Rice. 3. Reposition and retention of fragments of the humerus: a, b - with abduction fractures; c-d - for adduction fractures; e - thoracobrachial bandage; g - treatment according to Kaplan For abduction fractures, the traumatologist corrects the angular displacement with his hands, then reposition and immobilization are carried out in the same way as for adduction fractures. The duration of immobilization is from 6 to 8 weeks; from the 5th week, the shoulder joint is released from fixation, leaving the arm on the abduction splint. Rehabilitation time is 3-4 weeks. From the first day of immobilization, patients should actively move their fingers and hand. After turning the circular bandage into a sponge bandage (after 4 weeks), passive movements in the elbow joint are allowed (with the help of a healthy arm), and after another week - active ones. At the same time, massage and mechanotherapy are prescribed (for dosed load on the muscles). Patients practice exercise therapy daily under the guidance of a methodologist and independently every 2-3 hours for 20-30 minutes. After the patient is able to repeatedly raise his arm above the splint by 30-45° and hold the limb in this position for 20-30 seconds, the abduction splint is removed and rehabilitation begins in full. If closed reposition of the fragments fails, then surgical treatment is indicated (Fig. 4). Rice. 4. Osteosynthesis for a fracture of the surgical neck of the humerus, bone (a) and Ilizarov apparatus (b) After open reduction, the fragments are fixed with lag screws with a T-shaped plate. If the bone is osteoporotic, then knitting needles and a tightening wire suture are used. Four-part fractures of the head and neck of the humerus (type C2) are an indication for endoprosthetics. Fractures of the tuberosities of the humerus Causes. A fracture of the greater tuberosity often occurs with a dislocated shoulder. Its separation with displacement occurs as a result of a reflex contraction of the supraspinatus, infraspinatus and teres minor muscles. An isolated nondisplaced fracture of the greater tuberosity is primarily associated with a direct blow to the shoulder. Signs. Limited swelling, tenderness and crepitus on palpation. Active abduction and external rotation of the shoulder are impossible, passive movements are sharply painful. The diagnosis is confirmed by x-ray. Treatment. For fractures of the greater tubercle without displacement after blockade with novocaine, the arm is placed on an abductor pillow and immobilized with a Deso bandage or scarf for 3-4 weeks. Rehabilitation - 2-3 weeks. Working capacity is restored after 5-6 weeks. In case of avulsion fractures with displacement, after anesthesia, reposition is carried out by abduction and external rotation of the shoulder, then the limb is immobilized on an abduction splint or with a plaster cast (Fig. 5). Rice. 5. Fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - therapeutic immobilization For large edema and hemarthrosis, it is advisable to continue for 2 weeks. use shoulder traction. Abduction of the arm on the splint is stopped as soon as the patient can freely lift and rotate the shoulder. Rehabilitation - 2-4 weeks. Working capacity is restored after 2-21/2 months. Indications for surgery. Intra-articular supra-tubercle fractures with significant displacement of fragments, failed reduction in a fracture of the surgical neck of the humerus, entrapment of the greater tubercle in the joint cavity. Osteosynthesis is performed with a screw or a tightening wire loop (Fig. 6). Rice. 6. Surgical treatment of a fracture of the greater tubercle of the humerus: a - displacement of the fragment; b - fixation with a screw; c - fixation with wire Complications are the same as with shoulder dislocations. Traumatology and orthopedics. N. V. Kornilov The anatomical neck of the humerus is represented by a narrow groove that separates the spherical articular head from the main bone. In clinical practice, such fractures are rare. This fracture occurs when people of older age groups fall on the shoulder joint or, more often, on the abducted arm. Mostly these fractures are non-displaced and impacted, although cases with displacement or fracture-dislocations are also observed. Symptoms The victim complains of pain in the shoulder joint and impaired arm function. With the healthy arm, the victim supports the injured one, which is bent at the elbow joint and pressed against the body. The area of the shoulder joint is oval, evenly deformed, the contours are smoothed, the axis of the shoulder is not disturbed. For displaced fractures and fracture-dislocations, the shoulder appears shorter, the axis is shifted outward or inward. For fracture-dislocations there is no ovality of the shoulder joint; it has a steep contour like an epaulette. Active movements in the shoulder joint are impossible due to pain, passive movements are severely limited. Pain worsens upon palpation in the area of the projection of the head of the humerus, a positive symptom of fluctuation. Axial pressure on the shoulder also aggravates pain in the proximal end of the humerus, which does not happen with bruises. For impacted fractures active movements are limited, but possible. This causes diagnostic errors when a fracture must be differentiated from bruises of the shoulder joint. It is also clinically impossible to differentiate between fractures of the anatomical neck of the humerus without displacement and fractures without displacement or impacted surgical neck. In such cases, the final diagnosis is determined by x-ray examination. X-rays must be performed in 2 projections. Urgent Care Emergency care consists of pain relief and transport immobilization (with a metal splint, Deso bandage, scarf bandage or bandaging the injured arm to the body). Treatment Without displacement of fragments For non-displaced fractures, treatment is conservative. A puncture is performed, the accumulation of blood in the shoulder joint bursa is eliminated, and 20 ml of a 1% procaine solution is injected. A deep plaster splint is applied from the edge of the opposite scapula to the heads of the metacarpal bones and the hand is placed on a wedge-shaped pillow or immobilization is carried out with a Deso bandage. For victims with diseases of the chest organs, in elderly and weakened people, immobilization is carried out with a scarf bandage. With displacement of fragments A closed comparison of the fragments is carried out. 30-40 cm3 is injected into the shoulder joint (hematoma). 1% novocaine solution. After the onset of pain relief, in most cases, closed comparison of fragments is carried out in a sitting position. Weakened victims and children are placed on the table on their backs. An assistant standing behind the victim takes a towel folded in four or three times in length or a special flannel belt and throws it over the front surface of the shoulder joint so that one end passes over the shoulder girdle and the other under the armpit. With his left hand he grabs the upper end, and with his right hand he grabs the lower end and pulls them, fixing the shoulder joint. The surgeon takes the forearm in the lower third or the area of the wrist joint with his left hand, bends the forearm at the elbow joint to an angle of 90°, with the second hand grabs the shoulder by the lower third and gradually, effortlessly, with increasing strength, applies traction along the axis of the shoulder. In cases where the shoulder axis is deformed so that the angle is open outward, without weakening the traction along the axis, the doctor brings the shoulder to the midline of the body, and when the angle is open inward, he abducts the shoulder until the shoulder axis is restored. In this case, the shoulder is given a position of anterior deviation up to an angle of 60°. Having eliminated the deformity and restored the axis of the shoulder, a posterior plaster splint is applied from the edge of the opposite scapula to the head of the metacarpal bones. After the plaster has hardened, the hand is placed on a wedge-shaped pad. Immobilization lasts 3 weeks. If it is impossible to compare the fragments closed, as well as if there are contraindications to anesthesia under infiltration local anesthesia with the introduction of novocaine into the hematoma using the Mezoniev-Boden, Chaklin approaches, the joint is opened, blood clots and adhesions are removed, and the fragments are isolated. If the head is affected by a significant degenerative-dystrophic process with diffuse osteoporosis or the fracture is comminuted, then it is removed, as with comminuted fractures of the head. The proximal end of the distal fragment of the humerus is given an oval shape, placed at the level of the glenoid cavity of the scapula and the joint capsule is firmly sutured, after which the wound is sutured tightly. In cases where the structure of the head is satisfactory, without pronounced degenerative-dystrophic changes and the victim is not elderly, the fragments are compared and osteosynthesis is performed with screws or knitting needles. In the last decade, especially abroad, it has been considered advisable to replace the head with an endoprosthesis. Immobilization of the limb after surgery is carried out with a plaster splint with the arm placed on a wedge-shaped pillow or a CITO diversion splint for a period of 3-4 weeks. The shoulder joint is a movable connection of the humerus with the upper shoulder girdle, which includes the collarbone and scapula. The humerus is part of the upper limb. It is a tubular long bone that is an important anatomical structure because most of the muscles that move the upper limb are attached to it. In the proximal part of this bone there is the so-called head, which is part of the shoulder joint, thereby connecting the upper limb to the shoulder girdle (in particular with the scapula). The anatomical feature of the head of the humerus, which is part of the joint, allows the upper limb to make movements in different directions and in different ranges, thereby providing it with multifunctionality. In the process of evolution, the forelimbs lost their supporting function. As a result, primates stood on their hind legs, freeing their forelimbs for work and development. As a result of this process, the bones of the upper limbs became smaller and lighter than the bones of the lower limbs. Anatomical structure The structure of the human shoulder joint is somewhat complex. It consists of two main elements: shoulder blades; brachial bone; Spatula- a flat bone shaped like a triangle. It is located on the back side of the body, that is, on the back. The blade has three edges: upper; medial; lateral. The last edge, the lateral one, is particularly thick and massive, and also includes an articular cavity in its upper part, which is necessary for connecting the head of the humerus bone. This depression is equipped with a neck of the scapula, and directly above the depression there are two tubercles: the subarticular and supraglenoid. The scapular surface on the rib side is slightly concave, facing the chest and represents a subscapular cavity. The dorsal surface of the scapula is convex. You can touch it if you put your hands behind your back and feel the most convex part of your back. The dorsal surface has two muscles. The collarbone is part of the shoulder girdle. This is a tubular bone that has a curved shape in the form of an elongated letter S. It is the only bone that connects the upper limb to the skeleton of the body. Its functionality lies in the fact that it supports the scapular-humeral joint from the body at a certain distance. Thus, increasing the motor activity of the upper limb. The collarbone can be easily felt under the skin. It is attached to the sternum and shoulder blade by ligaments. The humerus is a tubular bone that has a special anatomical structure due to the attachment of muscles. It consists of two epiphyses (upper and lower) and a diaphysis located between them. The upper epiphysis consists of the head, which fits into the joint. The transition from this head to the body of the bone or diaphysis is called the anatomical neck or metaphysis. Outside the neck there are two tubercles to which the muscles are attached. The body of the bone has a triangular shape. Its head has a spherical shape, is turned towards the scapula and enters the shoulder joint. The greater and lesser tuberosities face outward and inward, respectively. A ridge extends from the hillocks, and there is a groove between them. The tendon of the head of the muscle passes through it. There is also the surgical neck, the narrowest part of the shoulder, located below the tuberosity. The shoulder joint is formed by the head of the humerus and the glenoid cavity. It has the shape of a hemisphere. The spherical shape of the surface determines the circular movements of the arm, since movements in the shoulder joint are often identified with movements of the arms. It is for this reason that an outstretched arm is able to describe a hemisphere in the air, that is, it moves forward and to the side only 90°. The shoulder joint has a smaller span. To raise your arm to the top, you need to involve the collarbone and scapula in the work. This joint is the most mobile, therefore it is subjected to heavy loads and is often injured. This also occurs due to the fact that the joint capsule is very thin, and the movements made by the joint have a large amplitude. The humeroradial joint is located between the humerus and the radius bone of the forearm. The acromial clavicular joint connects the clavicle to the acromial process of the scapula. Its articular surface is covered with cartilaginous and fibrous tissue. The acromion process can be felt by finding a hard bump on the back of the shoulder. Injuries and damage Due to its excessive physical activity, the humerus is susceptible to many injuries and damages. These include the following injuries and fractures: Dislocation It develops as a result of indirect injuries, that is, when falling on an outstretched arm or on the elbow, as well as from direct injuries, when a blow is struck to the shoulder. Dislocations are characterized by forward displacement of the head of the bone. Anterior dislocations occur more often than others. The injury is characterized by severe pain, swelling, hemorrhage and limited mobility. With posterior dislocations, the same symptoms are observed as with anterior ones. Dislocations may be accompanied by other injuries. For example, a large tubercle may come off or a surgical neck may fracture. In this case, it is necessary to check the sensitivity of the hand and arm. You cannot reduce a dislocation at the scene of an accident. Moreover, this cannot be done by people without special medical education. It is necessary to provide first aid and then transport the patient to a medical facility. First aid consists of fixing the shoulder using a special soft bandage in the form of a scarf. Dislocations can be reduced only in a medical facility and only under anesthesia. Fractures of the humerus can occur in several places: Fractures of the diaphysis of the bone Occurs due to a direct blow to the bone, as well as when falling on the elbow. In this case, deformation of the shoulder and its shortening and immobility, pain, crepitus, swelling, hematomas and pathological mobility are observed. When providing first aid, a splint is applied to the damaged area and the victim is given painkillers. Fractures of this kind in the lower and middle third are treated with skeletal traction, and injuries in the upper third of the shoulder are treated with the help of an abductor splint. Fractures of the anatomical neck of the bone Occurs due to a fall on the elbow or a direct blow. In case of neck injuries, fragments are pressed into the head of the bone. As a result, the head can become deformed, come off and shatter. Manifested by swelling, pain and hematoma. The functionality of the limb is strictly limited. A fracture of the anatomical neck can be impacted, then the symptoms do not appear so acutely, and the person is able to move the arm. Treatment can be either inpatient or outpatient. In both cases, a plaster splint is applied to accurately fix the shoulder in the correct physiological position. Analgesics and sedatives are prescribed. After removing the splint, wearing a scarf-type bandage is prescribed, as well as massage and phytotherapeutic procedures for a speedy recovery of the shoulder and limb. Full recovery occurs after 2-2.5 months. Distal fractures Such injuries are called extra-articular. They are flexion and extension depending on the injury received during a fall. Intra-articular - are injuries to the head of the condyle. It manifests itself as pain, crepitus, and pathological mobility. When providing first aid, the limb is immobilized using a scarf bandage. Painkillers are also administered. Surgical neck fractures Surgical neck injuries can be impacted or pinched. A displaced fracture can be abducted and externally displaced, and an angle is formed between the bone fragments. This type of damage is called adduction. It occurs when falling on an outstretched arm. If at the time of injury the shoulder was abducted and its central end moved inward, it is called abduction. When providing first aid, analgesics are administered, a splint is applied and the victim is transported to a medical facility. Tubercule fractures As a rule, tubercle injuries are dislocations. In this case, the tubercle is displaced and torn off due to reflex muscle contraction. With an isolated fracture of the tubercle, no displacement is observed. This causes pain, crepitus, swelling, and pathological mobility. First aid consists of applying a Deso bandage to secure the collarbone to the body; you can also use a soft bandage or scarf. The bandage is worn for approximately one month. If bleeding into the joint cavity (hemarthrosis) and swelling are observed within a month, then shoulder traction is prescribed for 15 days. The recovery period lasts one month. The shoulder is the proximal (closest to the torso) segment of the upper limb. The upper border of the shoulder is the line connecting the lower edges of the pectoralis major and latissimus dorsi muscles; lower - a horizontal line passing above the condyles of the shoulder. Two vertical lines drawn upward from the condyles of the shoulder conditionally divide the shoulder into anterior and posterior surfaces. External and internal grooves are visible on the anterior surface of the shoulder. The bony base of the shoulder is the humerus (Fig. 1). Numerous muscles are attached to it (Fig. 3). Rice. 1. Humerus: 1 - head; 2 - anatomical neck; 3 - small tubercle; 4 - surgical neck; 5 and 6 - crest of the lesser and greater tubercle; 7 - coronoid fossa; 8 and 11 - internal and external epicondyle; 9 - block; 10 - capitate eminence of the humerus; 12 - radial fossa; 13 - groove of the radial nerve; 14 - deltoid tuberosity; 15 - greater tubercle; 16 - groove of the ulnar nerve; 17 - ulnar fossa. Rice. 2. Fascial sheaths of the shoulder: 1 - sheath of the coracobrachial muscle; 2-radial nerve; 3 - musculocutaneous nerve; 4 - median nerve; 5 - ulnar nerve; 6 - sheath of the triceps brachii muscle; 7 - sheath of the brachial muscle; 8 - sheath of the biceps brachii muscle. Rice. 3. Places of origin and attachment of muscles on the humerus, right front (i), back (b) and side (c): 1 - supraspinatus; 2 - subscapular; 3 - wide (back); 4 - large round; 5 - coraco-humeral; 6 - shoulder; 7 - round, rotating the palm inward; 8 - flexor carpi radialis, superficial flexor carpi, palmaris longus; 9 - short radial extensor carpi; 10 - extensor carpi radialis longus; 11 - brachioradial; 12 - deltoid; 13 - greater sternum; 14 - infraspinatus; 15 - small round; 16 and 17 - triceps brachii muscle (16 - lateral, 17 - medial head); 18 - muscle that rotates the palm outward; 19 - elbow; 20 - extensor of the small finger; 21 - extensor fingers. The shoulder muscles are divided into 2 groups: the anterior group consists of flexors - biceps, brachialis, coracobrachialis, and the posterior group - triceps, extensor. The brachial artery, running underneath, accompanied by two veins and the median nerve, is located in the internal groove of the shoulder. The projection line of the artery on the skin of the shoulder is drawn from the deepest point to the middle of the cubital fossa. The radial nerve passes through the canal formed by the bone and triceps muscle. The ulnar nerve goes around the medial epicondyle, located in the groove of the same name (Fig. 2). Closed shoulder injuries. Fractures of the head and anatomical neck of the humerus are intra-articular. Without them, it is not always possible to distinguish from, and a combination of these fractures with dislocation is possible. A fracture of the tuberosity of the humerus is recognized only radiographically. A diaphysis fracture is usually diagnosed without difficulty, but is required to determine the shape of the fragments and the nature of their displacement. A supracondylar fracture of the humerus is often complex, T-shaped or V-shaped, so that the peripheral fragment is divided in two, which can only be recognized on an x-ray. Simultaneous dislocation of the elbow is also possible. With a diaphyseal fracture of the shoulder, the traction of the deltoid muscle displaces the central fragment, moving it away from the body. The closer to the broken bone the greater the displacement. When a surgical neck is fractured, the peripheral fragment is often driven into the central one, which is determined on the image and is most favorable for healing of the fracture. With a supracondylar fracture, the triceps muscle pulls the peripheral fragment backwards and upwards, and the central fragment moves anteriorly and downwards (towards the ulnar fossa), which can compress and even injure the brachial artery. First aid for closed fractures of the shoulder comes down to immobilizing the limb with a wire splint from the shoulder blade to the hand (the elbow is bent at a right angle) and fixing it to the body. If the diaphysis is broken and there is a sharp deformity, you should try to eliminate it by gently traction on the elbow and bent forearm. With low (supracondylar) and high shoulder fractures, attempts at reposition are dangerous; in the first case, they threaten to damage the artery, in the second, they can disrupt the impaction, if any. After immobilization, the victim is urgently sent to a trauma center for x-ray examination, reposition and further inpatient treatment. It is carried out, depending on the characteristics of the fracture, either in a plaster thoracobrachial bandage, or by traction (see) on an abduction splint. For an impacted neck fracture, none of this is required; the arm is fixed to the body with a soft bandage, placing a cushion under the arm, and after a few days therapeutic exercises begin. Uncomplicated closed shoulder fractures heal in 8-12 weeks. Shoulder diseases. Of the purulent processes, the most important is acute hematogenous osteomyelitis (see). After an injury, a muscle hernia may develop, most often a hernia of the biceps muscle (see Muscles, pathology). Among the malignant neoplasms, there are those that require amputation of the shoulder. Shoulder (brachium) is the proximal segment of the upper limb. The upper border of the shoulder is a line connecting the lower edges of the pectoralis major and latissimus dorsi muscles, the lower border is a line passing two transverse fingers above the condyles of the humerus. Anatomy. The skin of the shoulder is easily mobile, it is loosely connected to the underlying tissues. On the skin of the lateral surfaces of the shoulder, internal and external grooves (sulcus bicipitalis medialis et lateralis) are visible, separating the anterior and posterior muscle groups. The fascia of the shoulder (fascia brachii) forms a sheath for muscles and neurovascular bundles. The medial and lateral intermuscular septa (septum intermusculare laterale et mediale) extend from the fascia deep to the humerus, forming the anterior and posterior muscle containers, or beds. In the anterior muscle bed there are two muscles - biceps and brachialis (m. biceps brachii et m. brachialis), in the rear - triceps (m. triceps). In the upper third of the shoulder there is a bed for the coracobrachial and deltoid muscles (m. coracobrachialis et m. deltoideus), and in the lower third there is a bed for the brachialis muscle (m. brachialis). Under the fascia proper of the shoulder, in addition to the muscles, there is also the main neurovascular bundle of the limb (Fig. 1). Rice. 1. fascial receptacles of the shoulder (diagram according to A. V. Vishnevsky): 1 - sheath of the coracobrachialis muscle; 2 - radial nerve; 3 - musculocutaneous nerve; 4 - median nerve; 5 - ulnar nerve; 6 - sheath of the triceps brachii muscle; 7 - sheath of the brachial muscle; 8 - sheath of the biceps brachii muscle. Rice. 2. Right humerus in front (left) and back (right): 1 - caput humeri; 2 - collum anatomicum; 3 - tuberculum minus; 4 - coilum chirurgicum; 5 - crista tuberculi minoris; 6 - crista tuberculi majoris; 7 - foramen nutricium; 8 - facies ant.; 9 - margo med.; 10 - fossa coronoidea; 11 - epicondylus med.; 12 - trochlea humeri; 13 - capitulum humeri; 14 - epicondylus lat.; 15 - fossa radialis; 16 - sulcus n. radialis; 17 - margo lat.; 18 - tuberositas deltoidea; 19 - tuberculum majus; 20 - sulcus n. ulnaris; 21 - fossa olecrani; 22 - facies post. On the anterior-inner surface of the shoulder, two main venous superficial trunks of the limb pass over the proper fascia - the radial and ulnar saphenous veins. The radial saphenous vein (v. cephalica) runs outward from the biceps muscle along the external groove, at the top it flows into the axillary vein. The ulnar saphenous vein (v. basilica) runs along the internal groove only in the lower half of the shoulder, - the internal cutaneous nerve of the shoulder (n. cutaneus brachii medialis) (color table, Fig. 1-4). The muscles of the anterior shoulder region belong to the group of flexors: the coracobrachialis muscle and the biceps muscle, which has two heads - short and long; fibrous sprain of the biceps muscle (aponeurosis m. bicipitis brachii) is woven into the fascia of the forearm. Beneath the biceps muscle lies the brachialis muscle. All these three muscles are innervated by the musculocutaneous nerve (n. musculocutaneus). The brachioradialis muscle begins on the outer and anteromedial surfaces of the lower half of the humerus. Rice. 1 - 4. Vessels and nerves of the right shoulder. Rice. 1 and 2. Superficial (Fig. 1) and deep (Fig. 2) vessels and nerves of the anterior surface of the shoulder. Rice. 3 and 4. Superficial (Fig. 3) and deep (Fig. 4) vessels and nerves of the posterior surface of the shoulder. 1 - skin with subcutaneous fatty tissue; 2 - fascia brachii; 3 - n. cutaneus brachii med.; 4 - n. cutaneus antebrachii med.; 5 - v. basilica; 6 - v. medlana cublti; 7 - n. cutaneus antebrachii lat.; 8 - v. cephalica; 9 - m. pectoralis major; 10 - n. radialis; 11 - m. coracobrachialis; 12 - a. et v. brachlales; 13 - n. medianus; 14 - n. musculocutaneus; 15 - n. ulnaris; 16 - aponeurosis m. bicipitis brachii; 17 - m. brachialis; 18 - m. biceps brachii; 19 - a. et v. profunda brachii; 20 - m. deltoldeus; 21 - n. cutaneus brachii post.; 22 - n. cutaneus antebrachii post.; 23 - n. cutaneus brachii lat.; 24 - caput lat. m. trlcipitis brachii (cut); 25 - caput longum m. tricipitls brachii. The main arterial trunk of the shoulder - the brachial artery (a. brachialis) - is a continuation of the axillary artery (a. axillaris) and runs along the medial side of the shoulder along the edge of the biceps muscle along the projection line from the top of the axillary fossa to the middle of the cubital fossa. Two accompanying veins (vv. brachiales) run along the sides of the artery, anastomosing with each other (color. Fig. 1). In the upper third of the shoulder, outside the artery, lies the median nerve (n. medianus), which crosses the artery in the middle of the shoulder and then goes from its inside. The deep brachial artery (a. profunda brachii) arises from the upper part of the brachial artery. The nutrient artery of the humerus (a. nutrica humeri) departs directly from the brachial artery or from one of its muscular branches, which penetrates the bone through the nutrient foramen. Rice. 1. Cross cuts of the shoulder made at different levels. On the posterior-outer surface of the shoulder in the posterior osteo-fibrous bed there is a triceps muscle that extends the forearm and consists of three heads - long, medial and external (caput longum, mediale et laterale). The triceps muscle is innervated by the radial nerve. The main artery of the posterior section is the deep artery of the shoulder, running back and down between the external and internal heads of the triceps muscle and enveloping the humerus posteriorly with the radial nerve. In the posterior bed there are two main nerve trunks: radial (n. radialis) and ulnar (n. ulnaris). The latter is located superiorly posteriorly and internally from the brachial artery and median nerve and only in the middle third of the shoulder enters the posterior bed. Like the median nerve, the ulnar nerve does not give branches to the shoulder (see Brachial plexus). The humerus (humerus, os brachii) is a long tubular bone (Fig. 2). On its outer surface there is a deltoid tuberosity (tuberositas deltoidea), where the deltoid muscle is attached, and on the posterior surface there is a groove of the radial nerve (sulcus nervi radialis). The upper end of the humerus is thickened. There is a distinction between the head of the humerus (caput humeri) and the anatomical neck (collum anatomicum). The small narrowing between the body and the upper end is called the surgical neck (collum chirurgicum). At the upper end of the bone there are two tubercles: a large one on the outside and a small one in front (tuberculum inajus et minus). The lower end of the humerus is flattened in the anteroposterior direction. Outwardly and inwardly, it has easily palpable protrusions under the skin - the epicondyles (epicondylus medialis et lateralis) - the origin of most of the muscles of the forearm. Between the epicondyles is the articular surface. Its medial segment (trochlea humeri) has the shape of a block and articulates with the ulna; lateral - head (capitulum humeri) - spherical and serves for articulation with the ray. Above the trochlea in front is the coronoid fossa (fossa coronoidea), behind - the ulnar fossa (fossa olecrani). All these formations of the medial segment of the distal end of the bone are combined under the general name “condyle of the humerus” (condylus humeri). The shoulder joint (articulatio humeri) is the largest and most mobile joint of the upper limb, allowing the arm to perform a variety of movements. This amplitude is ensured by the special structure of the shoulder joint. It is located in the proximal parts of the upper limb, connecting it to the trunk. In a thin person, his contours are clearly visible. The articulatio humeri device is quite complex. Each element in the joint accurately performs its functions, and even a slight pathology of any of them leads to changes in the remaining parts of this structure. Like other joints of the body, it is formed by bone elements, cartilaginous surfaces, ligaments and a group of adjacent muscles that provide movement in it. What bones form the shoulder joint Articulatio humeri is a simple spherical joint. Its formation involves the humerus and scapula, which is part of the upper shoulder girdle. The articular surfaces covering the bone tissue are formed by the scapula and the head of the humerus, which is several times larger than the socket. This discrepancy in size is corrected by a special cartilaginous plate - the articular lip, which completely repeats the shape of the scapular cavity. Ligaments and capsule The articular capsule is attached around the circumference of the scapula at the border of the cartilaginous lip. It has different thicknesses, is quite free and spacious. Inside there is synovial fluid. The anterior surface of the capsule is the thinnest, so it is easily damaged in case of dislocation. Tendons attached to the surface of the capsule pull it back during arm movements and prevent it from being pinched between the bones. Some ligaments are partially woven into the capsule, strengthening it, while others prevent excessive extension when performing movements in the upper limb. Synovial bursae (bursae) articulatio humeri reduce friction between individual articular elements. Their number may vary. Inflammation of such a bursa is called bursitis. The most permanent bags include the following types: subscapular; subcoracoid; intertubercular; subdeltoid. The muscles play a key role in strengthening the shoulder joint and performing various movements in it. The following movements are possible in the shoulder joint: adduction and abduction of the upper limb in relation to the body; circular, or rotational; turns the arm inward, outward; raising the upper limb in front of you and moving it back; placing the upper limb behind the back (retroflexion). The articulatio humeri area is predominantly supplied with blood from the axillary artery. Smaller arterial vessels depart from it, forming two vascular circles - the scapular and acromial-deltoid. In case of blockage of the main line, the periarticular muscles and the shoulder joint itself receive nutrition precisely thanks to the vessels of these circles. The innervation of the shoulder is carried out by the nerves that form the brachial plexus. The rotator cuff is a complex of muscles and ligaments that together stabilize the position of the head of the humerus, participate in rotating the shoulder, and in lifting and flexing the upper limb. The following four muscles and their tendons are involved in the formation of the rotator cuff: supraspinatus, infraspinatus, subscapularis, small round. When the arm is raised, the rotator cuff slides between the head of the humerus and the acromion (articular process) of the scapula. To reduce friction, a bursa is placed between these two surfaces. In some situations, with frequent upward movements of the hand, this may occur. In this case, it often develops. It manifests itself as a sharp pain that occurs when trying to remove an object from the back pocket of your trousers. Microanatomy of the shoulder joint The articular surfaces of the scapula and the head of the humerus are externally covered with hyaline cartilage. Normally, it is smooth, which facilitates the sliding of these surfaces relative to each other. At the microscopic level, the collagen fibers of cartilage are arranged in arches. This structure contributes to the uniform distribution of intra-articular pressure that occurs during movement of the upper limb. The joint capsule, like a bag, hermetically covers these two bones. On the outside it is covered with a dense fibrous layer. It is further strengthened by interwoven tendon fibers. Small vessels and nerve fibers pass through the superficial layer of the capsule. The inner layer of the joint capsule is represented by the synovial membrane. Synovial cells (synoviocytes) are of two types: phagocytic (macrophage) - cleanse the intra-articular cavity from decay products; secretory - produce synovial fluid (synovium). The consistency of synovial fluid is similar to egg white, it is sticky and transparent. The most important component of synovium is hyaluronic acid. Synovial fluid functions as a lubricant for the articular surfaces and also provides nutrition to the outer surface of the cartilage. Its excess is absorbed into the vascular network of the synovial membrane. A lack of lubrication leads to rapid wear of the articular surfaces and. The structure of the human shoulder joint in pathology Congenital dislocation and subluxation of the shoulder are the most severe abnormal development of this joint. They are formed due to underdevelopment of the head of the humerus and processes of the scapula, as well as the muscles surrounding the shoulder joint. In the case of subluxation, the head, when the muscles of the shoulder girdle are tense, is automatically reduced and takes a position close to the physiological one. Then it returns to its usual, abnormal position. Underdevelopment of individual muscle groups (hypoplasia) involved in joint movements leads to limited range of motion in it. For example, a child cannot raise his arm above his shoulder and has difficulty placing it behind his back. On the contrary, with dysplasia articulatio humeri, which occurs as a result of abnormalities in the formation of the tendon-ligamentous apparatus of the joint, hypermobility develops (increased range of motion in the joint). This condition is fraught with habitual dislocations and subluxations of the shoulder. With arthrosis and arthritis, there is a violation of the structure of the articular surfaces, their ulceration, and the formation of bone growths (osteophytes). X-ray anatomy of the shoulder joint in normal and pathological conditions On an x-ray, the articulatio humeri looks like the picture below. The numbers in the figure indicate: Collarbone. Acromion of the scapula. Greater tubercle of the humerus. Lesser tubercle of the humerus. Shoulder neck. Brachial bone. Coracoid process of the scapula. Outer edge of the shoulder blade. Edge. An arrow without a number indicates the joint space. In the case of dislocation, inflammatory and degenerative processes, a change occurs in the relationship between the various structural elements of the joint and their location. Particular attention is paid to the position of the head of the bone and the width of the intraarticular gap. The photo of the radiographs below shows a dislocation and arthrosis of the shoulder. Features of the shoulder joint in children In children, this joint does not immediately take the same shape as in adults. At first, the greater and lesser tubercles of the humerus are represented by separate ossification nuclei, which subsequently merge and form the bone of a normal appearance. The joint is also strengthened due to the growth of ligaments and shortening of the distance between the bone elements. Due to the fact that the articulatio humeri in young children is more vulnerable than in adults, shoulder dislocations are periodically observed. They usually occur if an adult sharply pulls a child up by the hand. Some interesting facts about the articulatio humeri structure The special structure of the shoulder articulation and its component parts have a number of interesting features. Does the shoulder move silently? Compared to other joints of the body, for example, the knee, joints of the fingers, the spine, the articulatio humeri works almost silently. In fact, this is a false impression: joint surfaces rubbing against each other, sliding muscles, stretching and contracting tendons - all this creates a certain level of noise. However, the human ear distinguishes it only when organic changes are formed in the structure of the joint. Sometimes during jerking movements, for example, when a child is sharply pulled by the arm, you can hear popping sounds in the shoulder. Their appearance is explained by the short-term occurrence of a low-pressure area in the joint cavity due to the action of physical forces. In this case, gases dissolved in the synovial fluid, for example, carbon dioxide, rush into the area of low pressure, transform into gaseous form, forming bubbles. However, then the pressure in the joint cavity quickly normalizes, and the bubbles “burst”, making a characteristic sound. In a child, a crunch when moving the shoulder may occur during periods of increased growth. This is due to the fact that all articular elements of the articulatio humeri grow at different rates, and their temporary discrepancy in size also begins to be accompanied by a “crack.” Arms are longer in the morning than in the evening The joint structures of the body are elastic and resilient. However, during the day, under the influence of physical activity and the weight of one’s own body, the joints of the spine and lower extremities sag somewhat. This leads to a decrease in height by about 1 cm. But the articular cartilages of the shoulder, forearm and hands do not experience such a load, therefore, against the background of reduced height, they appear a little longer. Overnight, the cartilage is restored and growth becomes the same. Proprioception Some of the nerve fibers innervating the joint structures, thanks to special “sensors” (receptors), collect information about the position of the upper limb and the joint itself in space. These receptors are located in the muscles, ligaments, and tendons of the shoulder joint. They react and send electrical impulses to the brain if the position of the joint in space changes during arm movements, stretching of its capsule, ligaments, and contraction of the muscles of the upper shoulder girdle occurs. Thanks to such a complex innervation, a person can almost mechanically make many precise movements with his hand in space. The hand itself “knows” what level it needs to rise to, what turn to make in order to take an object, straighten clothes and perform other mechanical actions. It is interesting that in such moving joints as the articulatio humeri, there are highly specialized receptors that transmit information to the brain only for rotation in the cuff of the joint, adduction, abduction of the upper limb, etc. Conclusion The structure of the shoulder joint allows for optimal range of motion of the upper limb, meeting physiological needs. However, with weakness of the ligamentous apparatus of the shoulder and in childhood, dislocations and subluxations of the head of the humerus can be observed relatively often.